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Original article

Evaluation of sleep disorders in cancer patients based on

Pittsburgh Sleep Quality Index
TULAY AKMAN, MD, MEDICAL ONCOLOGY SPECIALIST, Tepecik Education and Research Hospital, Division of Medical
Oncology, Izmir, TUGBA YAVUZSEN, MD, ASSOCIATED PROFESSOR OF MEDICAL ONCOLOGY, Dokuz Eylul University
Medical School, Division of Medical Oncology, Izmir, ZEYNEP SEVGEN, MD, INTERNAL MEDICINE SPECIALIST, Dokuz
Eylul University Medical School, Department of Internal Medicine, Izmir, HULYA ELLIDOKUZ, MD, PROFESSOR
OF PUBLIC HEALTH, Dokuz Eylul University Medical School, Department of Preventive Oncology, Izmir, &

AHMET UGUR YILMAZ, MD, PROFESSOR OF MEDICAL ONCOLOGY, Medical Park, Izmir University, Division of Medical
Oncology, Izmir, Turkey

AKMAN T., YAVUZSEN T., SEVGEN Z., ELLIDOKUZ H. & YILMAZ A.U. (2015) European Journal of Cancer
Care
Evaluation of sleep disorders in cancer patients based on Pittsburgh Sleep Quality Index

Insomnia, poor sleep quality and short sleep durations are the most common problems seen in cancer patients.
More studies are needed about sleep disorders in cancer patients. In our study, we aimed to investigate the
prevalence of sleep disorders and the impact of these problems on the quality of life in cancer patients.
Pittsburgh Sleep Quality Index (PSQI) was given to a total of 314 patients. The psychometric evaluation of the
Turkish version of PSQI in cancer patients revealed that 127 (40.4%) patients had global PSQI scores >5,
indicating poor sleep quality. There was no statistically significant relationship between PSQI scores and
sexuality, marital status, cancer stage and chemotherapy type (P > 0.05); while the patients with bone and
visceral metastasis had much lower PSQI scores (P = 0.006). Patients with Eastern Cooperative Oncology
Group performance scores of 3 or more had also significantly lower PSQI scores (P = 0.02). In conclusion, PSQI
questionnaire may be used to evaluate the sleep disorders in cancer patients. Consistent use of multi-item
measures such as PSQI with established reliability and validity would improve our understanding of difficul-
ties experienced by cancer patients with chronic insomnia.

Keywords: sleep disorders, cancer patient, Pittsburg Sleep Quality Index.

INTRODUCTION an isolated complaint or as part of a symptom cluster

It is reported that cancer patients frequently experience
sleep disorders (Passik et al. 2003; O’Donnell 2004;
Theobald 2004; Sela et al. 2005; Davis and Goforth, 2014).
Among cancer patients, insomnia is considered as either
Correspondence address: Tulay Akman, MD, PhD student, Tepecik Edu-
cation and Research Hospital, Department of Medical Oncology, Gaziler
Caddesi, No: 468, Yenisehir, Izmir, Turkey (e-mail: tulaytuzel@gmail.com)
Commercial or financial support: Authors have no conflict of interest
(financial or otherwise). No commercial support was obtained for this
study.
Accepted 12 January 2015
DOI: 10.1111/ecc.12296
European Journal of Cancer Care, 2015
(Kirkova et al. 2011). Although insomnia is one of the
commonest and most distressing symptoms of cancer, it
has been largely ignored by clinicians and researchers;
there are a limited number of studies about assessment
and management of cancer-related insomnia (CRI) (Induru
& Walsh 2014).
Insomnia is a highly heterogeneous complaint described
as difficulty in falling asleep, trouble staying asleep
(waking up frequently and difficulty in sleeping again),
early morning awakening (with inability to resume sleep)
or a complaint of non-restorative sleep (Kvale & Shuster
2006). It is hard to evaluate the prevalence, type and the
severity of insomnia in cancer patients (Fortner et al.
2002). The prevalence varies from 19% to 63% due to

© 2015 John Wiley & Sons Ltd

AKMAN ET AL.
imprecise definitions and measurement (Kvale & Shuster
2006; Davis et al. 2013; Induru & Walsh 2014).
Approximately half of the cancer patients complain of
insomnia at certain stages of their disease and with
various severities of sleep loss. After cancer diagnosis, it
could be observed at any stage (Bastien et al. 2004; Clark
et al. 2004). Additionally, in years following diagnosis and
at the end of treatment, it is reported that in 23–44% of
cancer patients, insomnia may persist (Savard et al. 2001;
Flynn et al. 2010; Davis & Goforth 2014).
Insomnia should be evaluated based on the cancer type,
stage and the treatments administered. Its pathophysiol-
ogy is not clear, but many factors are likely causes of
insomnia among cancer patients. Insomnia in cancer
patients is associated with anxiety, depression and fatigue
(Kuo et al. 2006). Type of cancer treatments (chemo-
therapy, radiotherapy, hormonal treatments, etc.),
supportive care or concomitant medications (e.g.
corticosteroids, antiemetics, analgesics, antidepressants,
etc.), and other physical and psychological factors associ-
ated with cancer or not may be predisposing factors in
insomnia etiology (Donnelly et al. 2002; Graci 2005;
Kirkova et al. 2011; Davis & Goforth 2014). Age, gender,
familial or personal factors may also be predisposing
factors. It has been reported that the cancer type affects
sleep disorder prevalence and it is higher among lung,
breast and gynaecological cancer patients compared with
other cancer diagnoses (Christman et al. 2001; Davidson
et al. 2002).
Although insomnia is a very common problem in cancer
patients, its evaluation and treatment have not taken its
place in daily clinical application routines (Savard et al.
2001). One of the most important issues is the inadequate
evaluation of the patients (Berger et al. 2005; Berger 2009).
From medical literature, the lack of simple standard quan-
titative scales to measure insomnia prevalence in cancer
patients, and use of results from subjective and objective
studies, leads to variation in reporting insomnia (Morin
2000; Savard et al. 2001). There are different subjective
sleep evaluation methods and only a few can be used to
evaluate sleep quality and disorders in cancer patients
(Savard & Morin 2001; Berger et al. 2005; Davis et al.
2013). The most commonly used sleep disorder measure-
ment instruments for the general population are Insomnia
Severity Index, Epworth Sleepiness Scale, and Pittsburgh
Sleep Quality Index (PSQI) (Buysse et al. 1989). PSQI is a
self-evaluation questionnaire that has been used in the
general population and populations with different clinical
diagnoses including cancer patients and their relatives
(Beck et al. 2004; Clark et al. 2004; Berger et al. 2005;
Swore Fletcher et al. 2008). Agargün et al. (1996) con-
2 © 2015 John Wiley & Sons Ltd
ducted validity and reliability studies of this index in
Turkey. Many studies were done using the Turkish
version of PSQI (Aslan et al. 2010; Demiralp et al. 2010;
Buyukyilmaz et al. 2011; Oktem et al. 2013).
In this study, we used PSQI as the standard self-report
instrument in sleep disorder evaluation. The aim of this
study was to demonstrate the usability of PSQI, and to
evaluate the prevalence of insomnia symptoms and its
associations with patient demographics and clinical char-
acteristics via use of PSQI.
Patients and methods
This study was conducted at the Division of Medical
Oncology of the Department of Internal Medicine, Dokuz
Eylul University Medical School, Izmir, Turkey. The uni-
versity’s local ethical committee approval was obtained
before initiation of the study. The participants were out-
patients followed-up at our center and/or those receiving
chemotherapy at the chemotherapy unit, and all having
histopathologically proven cancer diagnoses. Confused or
agitated patients, hearing-impaired patients, patients with
delirium or those with an impaired level of consciousness
were excluded from the study. An informed consent form
was obtained from all patients. Socio-demographic and
clinical information was gathered for each patient from
their admission records.
In order to evaluate the sleep quality, PSQI was used, as
it is a reliable test with internal validity (Buysse et al.
1989). We have concluded that PSQI is an appropriate and
practical instrument to administer while studying sleep
disorders in cancer patients. The questions were asked in
a simple and clear manner and were understood easily by
all patients independent of their level of education. Addi-
tionally, it did not require a high level of training for the
clinicians and researchers to administer the tool. It has
been reported in medical literature that PSQI is a tool
easily accepted and applied to evaluate sleep disorders
among inpatients and outpatients with cancer (Beck et al.
2004). In our study, the physician completed the PSQI
during a face-to-face interview with each patient. PSQI is
a 19-item self-report questionnaire evaluating the sleep
quality and quantity among adults. It consists of 19 ques-
tions evaluating the following 7 domains: subjective sleep
quality (1 question), sleep latency (2 questions), sleep
duration (1 question), habitual sleep efficiency (3 ques-
tions), sleep disturbances (9 questions), use of sleep medi-
cation (1 question) and daytime dysfunction (2 questions).
Each question had a response scale with scores ranging
from 0 to 3, where 0 meant ‘very good’, 1 ‘fairly good’, 2
‘fairly bad’ and 3 ‘very bad.’ As a result, a global subjective
 Sleep disorders in cancer patients

sleep quality score between 0 and 21 is calculated based on Table 1. Demographic and clinical characteristics of the patients
the components mentioned. Higher scores indicate a (n) %
poorer sleep quality and a high level of sleep disorders. A Gender
global score of ≥5 clinically indicates that the patient’s Female 167 53.2
Male 147 46.8
sleep quality is significantly bad. PSQI’s diagnostic sensi-
Marital status
tivity is 89.6% and specificity is 86.5% (Buysse et al. Married 272 86.6
1989; Uysse et al. 1992; Agargün et al. 1996). Unmarried 42 13.4
Statistical analyses were performed with SPSS 15.0 ECOG performance status
0 186 59.2
software (SPSS Inc., Chicago, IL). All parameters were 1 97 30.9
reported with descriptive statistics. T-test and Mann– 2 21 6.7
Whitney U-test were used in comparison of continuous 3 10 3.2
parameters of groups based on good/bad sleep quality and Cancer type
Lung 68 21.7
gender. Categorical parameters were compared via χ2 test. Breast 71 22.6
Spearman’s correlation was used to evaluate the associa- Gastrointestinal 106 33.8
tions between sleep quality and other parameters. Logistic Urogenital 26 8.3
Other 43 13.7
regression was used to detect the parameters affecting the
Stage
sleep quality in the study group. Statistical significance Metastasis
level was set at P < 0.05. Present 243 77.4
Absent 71 22.6
Metastasis location
RESULTS Bone 57 18.2
Liver 55 17.5
Between February and December 2011, 371 patients were Lung 16 5.1
screened for eligibility. Three-hundred fourteen patients Brain 10 3.2
Other 105 –
were identified as eligible. Fifty-seven patients refused to
Median age of all patients was 58.5 (range, 28–84).
participate in the study due to lack of interest. Thus, final ECOG, Eastern Cooperative Oncology Group.
enrollment consisted of 314 participants. Patient demo-
graphics and clinical characteristics are presented in Table 2. Treatments received by patients
Table 1. Of the 314 patients, 167 (53.2%) were female and Drug therapy Yes (n) % No (n) %
147 (46.8%) were male. Median age of all patients was 58.5 Chemotherapy 186 59.2 128 40.7
(range, 28–84). The distribution of cancer diagnoses was Antiandrogen 8 2.5 306 97.4
as follows: 33.8% Gastrointestinal system (GIS), 22.6% Antiemetic 145 46.2 169 53.9
Antidepressant 21 6.7 293 93.3
breast cancer, 21.7% lung cancer, 8.3% gynaecological Psychostimulant 2 0.6 312 99.4
cancer and 13.7% other cancers. Treatments received by Antiestrogen 15 4.8 299 95.2
patients are presented in Table 2. Benzodiazepine 4 1.3 310 98.7
Sleep quality of 127 (40.4%) of patients was bad (global Bronchodilator 11 3.5 303 96.5
Corticosteroid 37 11.8 277 88.2
score >5). No statistically significant difference was Diuretic 21 6.7 293 93.3
observed between the sleep quality scores of patient Neuroleptic 3 1.0 311 99
groups based on gender, marital status, cancer stage or Biological agent 4 1.3 310 98.7
receiving chemotherapy (P > 0.05) (Table 3). When the
groups were compared based on metastasis location, those
DISCUSSION
with bone or visceral metastasis were found to have lower
sleep quality scores compared with others (P = 0.006). Prevalence of sleep disorders in cancer patients is twice
According to the general performance status of patients, that of the general population (Savard et al. 2003). Sleep
those with Eastern Cooperative Oncology Group scores of disorders are known to impact the quality of life and
3 had significantly lower sleep quality scores (P = 0.002). psychological well-being of cancer patients as well. Waking
When the patients were grouped based on gender, as was up frequently during the night for patients with cancer is
an independent factor affecting sleep quality according to the most common sleep disorder and is observed in 76% of
the sub-domains used in PSQI, the sleep disturbance and patients. Difficulty in falling asleep is observed in 44%,
daytime dysfunction scores were significantly higher waking for extended time periods is observed in 35% and
among women, while there were no significant differences waking early is observed in 33% (Savard et al. 2001;
observed on the other scales (P = 0.04; P = 0.01) (Table 4). Davidson et al. 2002). Many studies with related sleep

© 2015 John Wiley & Sons Ltd 3

AKMAN ET AL.

Table 3. The distribution of good and bad sleep quality according to the patient characteristics
Bad sleep Good sleep
quality (n) quality (n) Total (n) P-value*
Gender: 0.249
Female 73 94 167
Male 54 93 147
Marital status: 0.095
Married 105 167 272
Single 22 20 42
Stage: 0.074
Local disease: 22 49 71
Metastatic disease: 105 138 243
Metastasis location: 0.006
Visceral and bone 61 67 128
Brain and other 46 69 115
ECOG: 0.002
0 67 119 186
1 38 59 97
2 15 6 21
3 7 3 10
Receiving chemotherapy: 0.06
Yes 84 102 186
No 43 84 127
*χ2 statistical analysis results.

Table 4. Distribution of domain and global scores by gender in Pittsburgh Sleep Quality Index
Male (n: 147) Female (n: 167) Total (n: 314)
Component/domain score (0–3) Median (IQR) Median (IQR) Median (IQR) P-value
Subjective sleep quality 1,0 1,0 1,0 NS
Sleep latency 1,0 1,0 1,0 NS
Duration of sleep 0,0 0,0 0,0 NS
Habitual sleep efficiency 0,0 1,0 0,5 NS
Sleep disturbances 1,0 1,0 1,0 P = 0.04
Daytime dysfunction 0,0 0,0 0,0 P = 0.01
Sleep medication use 0,0 0,0 0,0 NS
Global score 4,0 5,0 5,0 NS
IQR, interquartile range.

disorders have been conducted by the researchers and cli-
nicians (Savard & Morin 2001; Vena et al. 2004; Page et al.
2006; Berger 2009). Sleep disorders can be evaluated sub-
jectively with methods involving self-report instruments
and sleep diaries, and objectively with methods such as
polysomnography and actigraphy (Berger et al. 2005;
Induru & Walsh 2014). However, lack of defined standard
quantitative screening criteria leads to obtaining various
different results (Morin 2000; Savard & Morin 2001). Lack
of sufficient easy-to-apply tools during routine healthcare
often results in an inability to survey insomnia-related
symptoms fully and leaving patients with underreported
sleep issues (Degner & Sloan 1995; Savard & Morin 2001;
Savard et al. 2001; Induru & Walsh 2014).
Forty percent of cancer patients had bad sleep quality in
this study. The prior researchers reported that insomnia
prevalence varies between 23–62% and 24–95%, and that
this rate is higher among cancer patients compared with
the general healthy population (Simeit et al. 2004). There
are various complex etiological factors impacting sleep
disorders in cancer patients. While demographic charac-
teristics such as age, gender, personality, traits, continu-
ous maladaptive sleep behaviors and their own and
familial history are important factors among those pre-
cipitating insomnia in cancer patients, predisposing
factors such as cancer type, cancer stage, physical and
psychological symptoms are also important (Fiorentino &
Ancoli-Israel 2006). Many prescription drugs can interfere
with sleep, including some antidepressants, antiemetics,
hormonal therapy (such as tamoxifen, leuprolide), heart
and blood pressure medications, opioids, neuroleptics
(such as methyphenidate) and corticosteroids. Coffee, tea,
cola and other caffeine-containing drinks and nicotine in
tobacco products are also well-known stimulants that can
cause insomnia (Induru & Walsh 2014). Also, insomnia
may be associated with cancer treatment side effects. Both

4 © 2015 John Wiley & Sons Ltd


chemotherapy and radiotherapy treatments have been
reported to be frequently associated with sleep disorders
(Irwin et al. 1992; Miaskowski & Lee 1999; Owen et al.
1999; Berger & Higginbotham 2000). Irrespective of the
type of the tumor, in 45% of the cancer patients who
underwent surgery, in 39% of patients who underwent
radiation therapy and in 35% of patients who underwent
chemotherapy, CRI is observed (Davidson et al. 2002; Lee
et al. 2004).
The results of this study showed that CRI is more
common among females and those with visceral and bone
metastasis. This is similar to findings of other studies in
medical literature, which concluded that sleep disorder
and daytime dysfunction scores were significantly higher
among females (Savard & Morin 2001; O’Donnell 2004;
Davis et al. 2013). While there are studies reporting that
insomnia is more common among the elderly, there are
also studies that report that it is not always the situation
(Davis et al. 2013). No statistical difference was detected
in terms of age in this study, either. Patients with bad
performance have been reported to have poorer sleep
quality and more sleep disorders compared with those
with better performance condition (Mystakidou et al.
2007). Our findings were in accordance with significantly
lower sleep quality scores detected among those with bad
general performance condition.
There are cancer specific precipitating factors and other
precipitating factors affecting anyone in the general
healthy population. These factors include age, gender, per-
sonal history of sleep problems and underlying psychiatric
diseases (Hearson & Sawatzky 2008).
Sleep problems can be present at all stages of the cancer
process: at the beginning of the treatment, at the time of
the surgery, during the anticancer treatment or during the
terminal stages. Even after the treatment period has
ended, insomnia issues may be present (Clark et al. 2004,
Induru & Walsh 2014). It is important to know if the sleep
disorder occurred prior to the cancer. Alcohol or substance
abuse, cardiac failure (which causes orthopnea) and
chronic obstructive pulmonary disease before the diagno-
sis of cancer must be queried (Davis & Goforth 2014).
Studies report that the sleep disorders persist in approxi-
mately 39–65% of cancer patients after treatment (Morin
2000; Berger et al. 2005). In breast cancer survivors,
insomnia and fatigue are found to be the most prevalent
and distress ing symptoms (Berger 2009).
A statistically significant difference was not observed
between the sleep quality scores of patients undergoing
chemotherapy and those on follow-up. This indicates that
sleep issues can be present before, during and after the
treatment and may not be directly associated with chemo-
© 2015 John Wiley & Sons Ltd
Sleep disorders in cancer patients
therapy. Because our study is a prevalence study, we could
not stratify the patients whether they were good or bad
sleepers before and after the diagnosis of cancer.
Sleep disorders and their prevalence have been shown to
vary by cancer type. A study has detected that sleep dis-
orders are more common in lung cancer patients when
compared with breast cancer patients, and that it is asso-
ciated with respiratory issues (Greenberg et al. 1993;
Silberfarb et al. 1993). Prevalence of insomnia syndrome is
highest among lung and breast cancer patients, and is
observed in other cancer types at various prevalence rates
as well (Davidson et al. 2002; Davis et al. 2013). In this
study, we did not determine a statistically significant dif-
ference in the sleep quality scores based on the type of
cancer diagnosed.
Few studies have been conducted on sleep disorders in
advanced metastatic diseases (Induru & Walsh 2014).
There are no studies in the medical literature demonstrat-
ing insomnia prevalence and severity by location of
metastasis. When evaluated by location of metastasis, the
findings of this study indicate that the sleep quality scores
in those with bone and visceral metastasis are lower than
others who have metastasis in other locations or no
metastasis.
Insomnia is a prominent cancer symptom, but this
symptom has received little attention by clinicians and
researchers (Savard et al. 2001; Davidson et al. 2002;
O’Donnell 2004; Kvale & Shuster 2006). CRI is frequently
observed concomitantly with other symptoms such as
pain, fatigue and psychiatric conditions such as anxiety,
depression and various mood disorders (Roscoe et al. 2007;
Davis et al. 2013).
In the literature, it was shown that the severity of
insomnia is moderately correlated with pain, depression
and fatigue symptoms. Also, pain is a symptom that nega-
tively affects falling and staying asleep (Tang et al. 2012).
In a study evaluating the predominant symptoms in
patients with advanced pancreatic cancer, 82% of patients
had pain and 54% of patients had sleep problems (Krech &
Walsh 1991). Insomnia has also been shown to be closely
associated with severity and continuity of fatigue (Abe
2012). The higher prevalence of insomnia among patients
with bone and visceral metastasis in this study may be
due to higher frequency of fatigue in these metastases. In
the first year after a cancer diagnosis in older adults, the
co-occurrence of pain, fatigue and insomnia has been asso-
ciated with increased risk of death, loss of follow-up and
increased reporting of other symptoms (Kozachik &
Bandeen-Roche 2008). An evaluation of other symptoms
was not conducted in our study; this is a limitation in our
study.
5
AKMAN ET AL.

Cancer-related insomnia (CRI) has a severe impact on
quality of life and increases symptom burden and distress
both directly and indirectly. CRI has adverse and diffuse
impact on cancer patients’ both physical and psychologi-
cal functions. Due to the unmanaged symptom of insom-
nia, the need for multiple hospitalisation and medical
consultation increases and, as a result, costs increase for
the health-care system (Davidson et al. 2002).
A primary limitation for this study has been the evalu-
ation of both patients undergoing chemotherapy as well as
patients that are being followed-up in an outpatient clinic.
Another limitation is the types of chemotherapy patients
had taken were not evaluated and other symptoms accom-
panying insomnia were not evaluated.
CONCLUSION
Insomnia seems to be a significant issue that is inad-
equately treated in this reasonable sample size of cancer
patients. The management of CRI is difficult because
there is lack of standardised definitions and guidelines
for the physician. As a result of this study, PSQI is an
appropriate and practical instrument that physicians
can administer while evaluating sleep disorders in
cancer patients. This study also indicated that sleep
disorders are more common in females, in those with a
bad performance condition and in those with bone and
visceral metastasis. Consequently, we determined a high
prevalence rate of insomnia at 40%. It is important
to evaluate and treat patients for insomnia before,
during and after cancer treatment. With better knowl-
edge of the nature and prevalence of sleep problems
among cancer patients, new approaches in supportive
care and new guidelines for the assessment and manage-
ment of CRI can be formed. The improvement in diag-
nosis and management of CRI will provide major
improvement in the symptom control of insomnia for
cancer patients.

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